Increasing the Use of Enteral Antibiotics in Hospitalized Children With Uncomplicated Infections.

BACKGROUND: Route of administration is an important component of antimicrobial stewardship. Early transition from intravenous to enteral antibiotics in hospitalized children is associated with fewer catheter-related adverse events, as well as decreased costs and length of stay. Our aim was to increase the percentage of enteral antibiotic doses for hospital medicine patients with uncomplicated common bacterial infections (community-acquired pneumonia, skin and soft tissue infection, urinary tract infection, neck infection) from 50% to 80% in 6 months. METHODS: We formed a multidisciplinary team to evaluate key drivers and design plan-do-study-act cycles. Interventions included provider education, structured discussion at existing team huddles, and pocket-sized printed information. Our primary measure was the percentage of antibiotic doses given enterally to patients receiving other enteral medications. Secondary measures included antibiotic cost, number of peripheral intravenous catheters, length of stay, and 7-day readmission. We used statistical process control charts to track our measures. RESULTS: Over a 6-month baseline period and 12 months of improvement work, we observed 3183 antibiotic doses (888 in the baseline period, 2295 doses during improvement work). We observed an increase in the percentage of antibiotic doses given enterally per week for eligible patients from 50% to 67%. We observed decreased antibiotic costs and fewer peripheral intravenous catheters per encounter after the interventions. There was no change in length of stay or readmissions. CONCLUSIONS: We observed increased enteral antibiotic doses for children hospitalized with common bacterial infections. Interventions targeting culture change and communication were associated with sustained improvement.

Food Waste from Campus Dining Hall as a Potential Feedstock for 2,3-Butanediol Production via Non-Sterilized Fermentation.

Food waste is a major issue that is increasingly affecting our environment. More than one-third of food is wasted, resulting in over $400 billion in losses to the U.S. economy. While composting and other small recycling practices are encouraged from person-to-person, it is not enough to balance the net loss of 80 million tons per year. Currently, one of the most promising routes for reducing food waste is through microbial fermentation, which can convert the waste into valuable bioproducts. Among the compounds produced from fermentation, 2,3-butanediol (2,3-BDO) has gained interest recently due to its molecular structure as a building block for many other derivatives used in perfumes, synthetic rubber, fumigants, antifreeze agents, fuel additives, and pharmaceuticals. Waste feedstocks, such as food waste, are a potential source of renewable energy due to their lack of cost and availability. Food waste also possesses microbial requirements for growth such as carbohydrates, proteins, fats, and more. However, food waste is highly inconsistent and the variability in composition may hinder its ability to be a stable source for bioproducts such as 2,3-BDO. This current study focuses specifically on post-consumer food waste and how 2,3-BDO can be produced through a non-model organism, Bacillus licheniformis YNP5-TSU during non-sterile fermentation. From the dining hall at Tennessee State University, 13 food waste samples were collected over a 6-month period and the compositional analysis was performed. On average, these samples consisted of fat (19.7%), protein (18.7%), ash (4.8%), fiber (3.4%), starch (27.1%), and soluble sugars (20.9%) on a dry basis with an average moisture content of 34.7%. Food waste samples were also assessed for their potential production of 2,3-BDO during non-sterile thermophilic fermentation, resulting in a max titer of 12.12 g/L and a 33% g/g yield of 2,3-BDO/carbohydrates. These findings are promising and can lead to the better understanding of food waste as a defined feedstock for 2,3-BDO and other fermentation end-products.

Pediatric Hospitalists' Performance of Recommended Minor Procedures: A Multicenter Study.

BACKGROUND AND OBJECTIVES: Performance of minor procedures is highly variable among pediatric hospitalists. Our objective was to describe procedural frequency and measure self-assessed competence in recommended minor procedures among practicing hospitalists. METHODS: An electronic survey was administered across 20 US institutions. An individual survey assessed training, frequency, independence, and success in performing 11 minor procedures. The site survey described practice settings at participating study sites. The primary outcome was respondents' self-assessed competence (SAC), derived by averaging self-assessed independence and success scores (each on a 5-point Likert scale) across all 11 minor procedures. Associations between predictor variables and SAC were determined through analysis of variance for categorical variables and fitted regression models for continuous variables. RESULTS: Of the 360 survey respondents, the majority were female (70%), not fellowship trained (78%), and had 10 years or fewer experience as a hospitalist (72%). Lumbar puncture and bag mask ventilation were most frequently performed. Greater procedural frequency and time since graduation from training were associated with higher SAC scores among respondents. Practice characteristics, including comanagement of patients and reserved time for practicing procedures, were associated with higher SAC scores. The presence of a simulation center and fellowship program was not associated with higher SAC scores. CONCLUSIONS: Pediatric hospitalists that performed procedures more frequently had higher self-assessed procedural competence. Tailored opportunities with increased hands-on experience in performing minor procedures may be important to develop and maintain procedural skills.

Risk Factors for the Development of Hospital-Associated Venous Thromboembolism in Adult Patients Admitted to a Children's Hospital.

BACKGROUND AND OBJECTIVES: Hospital-associated venous thromboembolism (HA-VTE) is a leading cause of preventable in-hospital mortality in adults. Our objective was to describe HA-VTE and evaluate risk factors for its development in adults admitted to a children's hospital, which has not been previously studied. We also evaluated the performance of commonly used risk assessment tools for HA-VTE. METHODS: A case-control study was performed at a freestanding children's hospital. Cases of HA-VTE in patients ≥18 years old (2013-2017) and age-matched controls were identified. We extracted patient and HA-VTE characteristics and HA-VTE risk factors on the basis of previous literature. Thrombosis risk assessment was performed retrospectively by using established prospective adult tools (Caprini and Padua scores). RESULTS: Thirty-nine cases and 78 controls were identified. Upper extremities were the most common site of thrombosis (62%). Comorbid conditions were common (91.5%), and malignancy was more common among case patients than controls (P = .04). The presence of a central venous catheter (P < .01), longer length of stay (P < .01), ICU admission (P = .005), and previous admission within 30 days (P = .01) were more common among case patients when compared with controls. Median Caprini score was higher for case patients (P < .01), whereas median Padua score was similar between groups (P = .08). CONCLUSIONS: HA-VTE in adults admitted to children's hospitals is an important consideration in a growing high-risk patient population. HA-VTE characteristics in our study were more similar to published data in pediatrics.

Things Are Not Always What They Seem: Two Cases of Child Maltreatment Presenting With Common Pediatric Chief Complaints.

We describe 2 cases of child maltreatment who presented as common pediatric conditions: preseptal cellulitis and gastroenteritis. The first case is an 8-year-old girl who presented with progressive right eye pain, swelling, and discharge. She was initially treated for preseptal cellulitis, but eye cultures ultimately grew Neisseria gonorrhoeae. Further investigation revealed sexual abuse by a male family member. The second case is a 2-year-old previously healthy girl who presented with 6 hours of emesis, lethargy, and abdominal pain. Initially attributed to viral gastroenteritis, her serum blood urea nitrogen and creatinine were above what was expected for her clinical course, and she later developed signs of peritonitis. She was ultimately found to have a large bladder wall defect secondary to inflicted blunt abdominal trauma. These cases are presented to emphasize the need for pediatricians to consider child abuse even when patients present with common pediatric complaints.